Provider Demographics
NPI:1932664190
Name:DCCCA, INC.
Entity Type:Organization
Organization Name:DCCCA, INC.
Other - Org Name:DCCCA BEHAVIORAL HEALTH PRATT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KERYE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-841-4138
Mailing Address - Street 1:3312 CLINTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-3624
Mailing Address - Country:US
Mailing Address - Phone:785-841-4138
Mailing Address - Fax:785-841-5777
Practice Address - Street 1:501 S NINNESCAH ST
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-2838
Practice Address - Country:US
Practice Address - Phone:620-672-7546
Practice Address - Fax:620-672-7148
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DCCCA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-01
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200655670TMedicaid